Provider Demographics
NPI:1407896046
Name:RAUCH, MARTIN W (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:W
Last Name:RAUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-445-2983
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-445-2983
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG741482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G741480Medicaid
CA00G741480OtherBLUE SHIELD
CABG446ZMedicare PIN
CAAP434YMedicare PIN
CA00G741480OtherBLUE SHIELD
CAF66904Medicare UPIN
CA00G741480Medicaid
CAWG74148MMedicare PIN
CAW16629Medicare PIN
CAWG74148BMedicare PIN
CAAP434ZMedicare PIN
CAWG74148NMedicare PIN